Long-Term Outcomes and Complications from Endoscopic Versus Microscopic Transsphenoidal Surgery for Cushing's Disease: A 15-Year Single-Center Study.

BACKGROUND: Endoscopic endonasal surgery is the main transsphenoidal approach for pituitary surgery in many centers; however, few studies compare the endoscopic and microscopic surgical approaches with regard to long-term follow-up. This single-center study aimed to compare the 2 techniques over 15 years. METHODS: Medical records and magnetic resonance images from 40 patients with primary transsphenoidal surgery for Cushing's disease at Sahlgrenska University Hospital between 2003 and 2018 were reviewed. 14 patients who underwent microscopic surgery and 26 patients who underwent endoscopic surgery were included in this study. RESULTS: In the microscopic group, 12 of 14 patients achieved endocrine remission, compared to 19 of 26 patients in the endoscopic group (n. s.). Three patients in each group developed a late recurrence. Complications were seen in 5 patients in the microscopic group and in 8 patients in the endoscopic group (n. s.). No serious complications, such as carotid artery damage, cerebrovascular fluid leakage, epistaxis, or meningitis, occurred in any group. The postoperative hospital stay was shorter in the endoscopic than in the microscopic group. CONCLUSIONS: Endoscopic endonasal surgery for Cushing's disease showed no difference in remission, recurrence, and complication rates compared to the microscopic approach. The endoscopic group had a shorter postoperative hospital stay than the microscopic group, which in part may be due to the minimal invasiveness of the endoscopic approach.

Heparin and Protamine Titration Does Not Improve Haemostasis after Cardiac Surgery: A Prospective Randomized Study.

BACKGROUND: Bleeding complications are common in cardiac surgery. Perioperative handling of heparin and protamine may influence the haemostasis. We hypothesized that heparin and protamine dosing based on individual titration curves would improve haemostasis in comparison to standard dosing. SUBJECTS AND METHODS: Sixty patients scheduled for first time elective coronary artery bypass grafting or valve surgery were included in a prospective randomized study. The patients were randomized to heparin and protamine dosing with Hepcon HMS Plus device or to standard weight and activated clotting time (ACT) based dosing. Blood samples were collected before and 10 minutes, 2 hours and 4 hours after cardiopulmonary bypass. Primary endpoint was endogenous thrombin potential in plasma 2 hours after surgery as assessed by calibrated automated thrombography. Secondary endpoints included total heparin and protamine doses, whole blood clot formation (thromboelastometry) and post-operative bleeding volume and transfusions. Heparin effect was assessed by measuring anti-Xa activity. RESULTS: Endogenous thrombin potential and clot formation deteriorated in both groups after surgery without statistically significant intergroup difference. There were no significant differences between the groups in total heparin and protamine doses, heparin effect, or postoperative bleeding and transfusions at any time point. Significant inverse correlations between anti-Xa activity and endogenous thrombin potential were observed 10 min (r = -0.43, p = 0.001), 2 hours (r = -0.66, p<0.001) and 4 hours after surgery (r = -0.58, p<0.001). CONCLUSION: In conclusion, the results suggest that perioperative heparin and protamine dosing based on individual titration curves does not improve haemostasis after cardiac surgery. Postoperative thrombin generation capacity correlates to residual heparin effect. TRIAL REGISTRATION: www.isrctn.com ISRCTN14201041.

A structured blood conservation programme reduces transfusions and costs in cardiac surgery.

OBJECTIVES: Transfusions of blood products can be lifesaving, but they are also associated with considerable risks and adverse effects, including immune response and infections. In cardiac surgery, transfusions have also been associated with increased mortality. We prospectively studied the effects of a structured programme to reduce transfusions and transfusion-associated costs in cardiac surgery. METHODS: The programme included: (i) education of all staff about the risks and benefits of blood transfusions; (ii) revised guidelines for transfusions; and (iii) a transfusion log where indication for transfusion, status of the patient and prescribing physician were registered. Transfusion prevalence, complications and costs for blood products were registered for all acute and elective cardiac operations during a 12-month period before (n = 1128) and after (n = 1034) the programme was started. The two time periods were compared. In addition, the prevalence of transfusions was registered for 2 more years after the programme was initiated. RESULTS: The first year after the programme was initiated the proportion of patients transfused with red blood cell concentrate decreased by 21.8% (from 58.2 to 45.5%, P <0.001), plasma by 37.4% (from 30.8 to 19.3%, P <0.001) and platelets by 21.0% (from 20.5 to 16.2%, P = 0.010). Reoperations for bleeding (5.8 vs 5.0%), early complication rate and 30-day mortality (2.5 vs 2.6%) were not significantly different before and after the start date. Based on the 2009 institutional prices for red blood cell concentrate (102 €/unit), plasma (35 €/unit) and platelets (290 €/unit), the savings on blood products were €161,623 during the first 12 months after the programme was launched. The proportion of patients transfused with any blood product was 60.9% before the programme was started and 48.3, 54.0 and 50.7% 1-3 years after its start (all P <0.001), respectively. CONCLUSIONS: A structured blood conservation programme reduces transfusions and costs for blood products in cardiac surgery, without any signs of compromised medical safety. The effects of introducing such a programme are maintained over at least 3 years.

Low preoperative fibrinogen plasma concentration is associated with excessive bleeding after cardiac operations.

BACKGROUND: Data from small selected patient populations suggest that the preoperative plasma concentration of fibrinogen influences postoperative blood loss and red blood cell transfusion after cardiac operations, but there are also conflicting reports. We assessed the importance of preoperative fibrinogen concentration for excessive bleeding and red cell blood transfusion in a large cohort of mixed cardiac surgical patients. METHODS: We included 1,954 cardiac surgical patients in a prospective observational study. The fibrinogen plasma concentration was measured on the day before the operation. Blood loss (mediastinal drain volume) during the first 12 postoperative hours and red blood cell transfusion during the hospital stay were registered and related to fibrinogen concentration with logistic regression models. Excessive bleeding was defined as postoperative blood loss exceeding 1,000 mL/12 hours. RESULTS: The preoperative fibrinogen concentration was inversely proportional to the prevalence of excessive bleeding in univariate testing (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.64 to 0.89 per g/L; p=0.001) and also in a multiple model adjusted for age, sex, body mass index, renal function, acuteness of the operation, cardiopulmonary bypass time, clopidogrel use less than 5 days before the operation, and type of operation (OR for fibrinogen, 0.82; 95% CI, 0.69 to 0.97; p=0.024). In contrast, the prevalence of red cell blood transfusion increased with increasing fibrinogen levels in univariate testing (OR, 1.36; 95% CI, 1.24 to 1.49; p<0.001) but not in a multiple model (OR, 1.10; 95% CI, 0.89 to 1.28; p=0.49). CONCLUSIONS: Preoperative plasma concentration of fibrinogen is independently associated with excessive bleeding after cardiac operations but not with red blood cell transfusion.